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Can Information Technology, Nursing and Informatics
Shape Operations? A Case Study
Session 167, February 13
th
, 2019
Michelle Machon, RN, MSN, Director, Clinical Ed., Practice & Informatics, Kaiser Permanente
Edwina Bhaskaran, RN, MSN, Division Director Clinical Informatics, CHI Texas Division
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Edwina Bhaskaran
Michelle Machon
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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Journey
Background: What makes this discussion unique? Or is it?
It started with IT: The Technology & Approach
The People Factor
To get to the Process
Summary
The Challenges
Outcomes
Recommendations
Agenda
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Demonstrate the advantages of information and technology,
informatics and clinical partnerships during an EMR
implementation
Create a strategy for robust relationships with departments where
strong partnerships are not the norm
Identify the opportunities within organizations for managing the
issues that arise within greenfield projects
Apply their learning's to their own organizations as information and
technology, clinical informatics and nursing work together
Identify the challenges of opening a “first of its kind” American
healthcare system in the Middle East
Learning Objectives
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Clinical Applications Director
IT Employee # 2
Clinical Informatics Director
Nursing Employee # 1
Clinical Educator and Unit Manager
Clinical Educator # 1
Introductions & Background
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Case Study: Background and Mission
Replicate the First US Multispecialty Hospital Outside North
America
Cultivate a Sustainable Healthcare System
Support the Development of Local Healthcare Talent
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Traditional Approach
“IT should never lead
operations”
People
Process
Technology
Technology
People
Process
Go-Live
First Patient
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1. The Technology
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Implementation Complexity
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Operational processes are now embedded within
EMR more than ever.
In this case:
EMR served as an “anchor” implementation project for the IT
Portfolio and for clinical operations
Timeline & Strategy
Integration
Focus on EMR Implementation
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Greenfield EMR Implementation Goal
Existing Organization EMR Initiative Greenfield EMR Initiative
Existing Process Optimizing Process
Input
Process Establishment
Implementation Input
Operation Process &
Policy
Technology Variables
GOAL: Operational Optimization & Efficiency GOAL: Establish Operations
Initiative Objective:
Implementation of an integrated Electronic Medical Record system that supports hospitals future
vision for patient care and will serve as the foundation for future optimization (captured during
implementation).
Accomplished By:
Use existing EMR as a point of reference
Leveraging industry standards to establish interoperability standards and functions
Rigorous documentation of implementation process, decisions, assumptions that will provide
historical background
Implementation
Input
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Content for EMR Design
EMR Design/Build Inputs
Process Flows
Regulatory Information
Operating Models
Organization Charts
Staffing Plans
Policies and Procedures
Scope of Services
Physical Locations
Determining IP vs. OP areas
Specialties
Clinical Documentation Standards
In a standard EMR
implementation,
hospitals have provided
services and many of
the information listed
already exist.
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A different approach was required….
The EMR Design Process included six steps per workflow validation
session. Each session required approximately 22.25 hours per session in
preparation time. This yielded a 96 % validation rate.
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Design Deliverables
EMR IT Workflow Validation Schedule
Schedule of 149 sessions
EMR IT Workflow Validation Materials
EMR IT Workflow Presentations
Strategy Session
Documented decisions from Strategy
Sessions
Deviations
Documented differences in the
sequence of which activities are
completed by an end user within an
application, or in the point of reference
system
Design Deliverables Under
Change Control
EMR IT Workflow Visios
446 EMR IT Workflow Visios and a Table of
Contents listing co-dependent EMR IT Workflows
Business Operations Input Toolkit
806 Business Operational questions that define
the design of the system
Functionality Matrix
Reference document to show the Epic
functionality that will be used
Facility Organization Structure
Document detailing departments, locations and
service areas
Design Deliverables
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The most significant challenge to completion of the EMR build was lack of operational
resources and schedule maintenance. The EMR and operations teams re-visited SME
identification, schedule approach and overall process several times during the course
of Workflow and Content Validation.
Scheduling
Established Operational Identification Owner (OIO) group to act as operational champions
for the EMR Validation Schedule
Had dedicated EMR Scheduling Analyst to manage schedule and meeting invites
Used Change Control process to track changes
EMR Validation Schedule Facts
890 instances of session rescheduling
487 (54.7%) rescheduled sessions due to business
operations availability
305 (34.3%) rescheduled sessions due to other EMR team
changes (usually shortening of sessions)
51 (5.7%) rescheduled sessions due to follow up not being
completed on time
33 (3.7%) rescheduled sessions due to EMR Project Team
availability
14 (1.6%) rescheduled sessions due to other reason
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2. The People
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The most crucial success factor for EMR implementations is
operational involvement and input.
When the EMR Implementation commenced the following
individuals provided operational involvement:
Let’s talk about people…
Medical Informatics Director
Clinical Informatics Director
Chief Nursing Officer
Chief Medical Officer
Pharmacy Director
Administrative Services Director
Revenue Cycle Director
Finance Director
……that’s it!
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200 design sessions back at Main Campus to prepare the on site
SMEs with a “frame of reference”
Process Framework
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The IT strategy was based on replication from reference
US site
Became evident that answers were required to questions
that the newly hired clinicians had not considered.
As the implementation progressed, the differences were
evident:
Cultural
Regulatory
Facility differences
More complex issues such as
Anglicized spelling and date format
DNR status
Patient naming convention
Fasting during Ramadan.
The Relationship Begins…
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This could have caused friction
however….
The key clinical and informatics stakeholders
realized that this was an opportunity to form
innovative collaboration avenues and they
took advantage and respected the direction IT
was bringing to the clinical staff
Information Technology adapted to provide
flexibility while meeting implementation
timelines.
Evolution of a Partnership
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Operational Resources were sought with these
skills
With local operational clinical experience
With Main Campus clinical and IT Experience
With EMR experience
With Project Management experience
Resources Skill Mix
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Back in the States
SMEs from every area were referred to daily
From external local organizations
Other hospitals
Payors
Regulators
More Partnerships…
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3. The Processes
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Operational Questions Examples
Scope of Practice
What is the scope of practice for
Physician Extenders and Associate
Physicians?
Scope of Services
What types of organ transplants do you
plan to perform?
Do any of these types require specialized
units? How often do you expect to be
doing these transplants ?
Patient Flow
Where will direct admission patients
arrive in the hospital? A registration
desk, the ED or directly on the floor?
Will this change based on acuity or
time of day?
Policy
Will a second signature (not a co-sign) for
specific medications (i.e. antibiotics) from
infectious disease be required? If not, will
Pharmacy restrict the ordering of certain
medications to specific medical specialties
(Infectious Disease)?
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1. IT generated “design questions”
2. Needed a forum for these discussions which
became a multidisciplinary committee
responsible for the clinical decisions needed
“Informatics Clinical Advisory Group
(iCAG)
Example:
- “how often will you be reassessing your
patients in pain”
- “how often are you documenting on patients
in restraints”.
A Process to get to the Process
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The options were trifold:
let iCAG decide the processes,
look to the evidence
reach back to the main campus in the
States.
All three of these were utilized
IT drove timelines, deadlines and
the project plan in general.
Operational Process Evolution
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The Challenges
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Challenge:
The local cultural, regulatory and legal
environment prevented a replication of the US
processes in the UAE
Solution:
Every single US process, document, order set
and workflow had to be touched and revisited
for the environment of the new facility.
Different processes “in-country”
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Challenge:
Only IT workflows had been documented
Solution:
Utilizing the index from a
standard nursing textbook and
the IT workflows, the basis of
nursing operations was formed.
Lack of clinical workflows
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Challenge
Bigest Bang” go live:
- All Clinical Applications, including the EMR
- All Medical Equipment + Device Integration
- All hospital policies & procedures, job orientation,
department orientation.
- Everyone was onboarding together, at the
same time.
Solution
A highly coordinated operations training plan
orchestrated by the IT PMO
Multiple Workstreams
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Challenge:
The original construction timeline elongated
and so did the correlating IT implementation/
EMR build. New employees were onboarded
during these delays and there were challenges
with these new SMEs asking for new iterations
of the formal design
Solution:
Workflows that were developed were placed
under “change control” and incorporated into
the IT change control process
Extended timeline and changes
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Resources eventually came but…
The EMR Team ran monthly sessions for new hires as an introduction
to the EMR, including work-to-date to design, build, test the EMR
system, policies and procedures related to workflow and/or content
changes, and related IT PMO processes.
Approach
Audience
Type of Orientation
Physicians (Chairs)
One-on-One Meeting
Frequency: As needed
Topics Covered:
o EMR Overview
o Demonstration of related Epic functionality
o Governance and Change Control Process
Physicians (Non-Chairs),
Nursing Directors, Finance
Directors, Department
Administrators
“Introduction to EMR” Session
Frequency: Monthly
Topics Covered:
o EMR Overview
o Demonstration of related Epic functionality (breakout session)
Governance and Change Control Process
Managers, Analysts
None
Tools / Supporting Documentation
Powerpoint Presentation
Epic System Demonstration
Access to EMR Sandbox
EMR IT Workflows
Validation Session Materials
EMR Decisions & Assumptions
Documentation
Epic Glossary
Epic E-Learning
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Challenge:
frontline staff were not immediately using the
system so knowledge gained was often lost
learning multiple business/clinical apps at once
meant the caregivers were often confused/ had
cognitive overload
Solution:
Hundreds of end-to-end multi-disciplinary
walkthroughs
Post go-live round the clock shoulder to shoulder
support, geographically located in depts
Peer to peer (super-user) learning was vital.
Training
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70+ Applications to train on
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Challenges
After opening- clinicians wanted nearly every
process to be adapted, changed or
redesigned
Solutions
Strong leadership commitment to a
governance process
Post go-live Change requests
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Eventually worked with IT to put a
change management process in place…
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The End Result
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Trust
Operations needed to rely heavily on IT expertise.
IT needed to rely heavily on operations to keep the
implementation moving.
Collaboration
Approach needed to be modified several times over
the course of the implementation to facilitate changes
to hospital operations (e.g. organ donation)
Open (Effective) Communication
Welcomed and acknowledged risk and issues
Partnership
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Facility opened HIMSS stage 7 enabled
• Virtually “paper” less system
IT Implementation enabled hospital operations
and provided a foundational system for
optimization
Result
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The Recommendations
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View go-live as a “phase”
Plan resources to projected patient
volume
Create an agile governance process
Recommendations from IT
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Create a robust Mock Operations
plan
Mirror your “Sandbox” environment
as close to reality as possible
Remember that “perfection is the
enemy of progress” (Winston
Churchill) .
Recommendations from Nursing
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Maintain your strategic partnerships
Create a strong clinical governance
process pre-opening.
Do not be “married” to your build.
Set very clear expectations with your
Clinicians
Recommendations from Informatics
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Michelle Machon, RN, MSN
Edwina Bhaskaran, RN, MSN
Please complete your evaluations!
Questions